02-031-850 Me. Code R. § 10

Current through 2024-46, November 13, 2024

Section 031-850-10 - Grievance Register and Grievance Procedures

A.Grievance Register

1) A health carrier shall maintain written records to document all grievances received during a calendar year (the register). Standard and expedited appeals pursuant to subsection 8(G) of this rule shall not be considered grievances for purposes of the grievance register. For each grievance the register shall contain, at a minimum, the following information:

a) A general description of the reason for the grievance;

b) Date received;

c) Date of each review or hearing;

d) Resolution at each level of the grievance;

e) Date of resolution at each level; and

f) Name of the covered person for whom the grievance was filed.

2) The register shall be maintained in a manner that is reasonably clear and accessible to the Superintendent.

3) A health carrier shall retain the register compiled by calendar year for the longer of 3 years or until the Superintendent has adopted a final report of an examination that contains a review of the register maintained for the period of the examination.

B.Grievance Procedure

A health carrier shall establish and implement written procedures for receiving and resolving grievances from covered persons consistent with the requirements of this section, and sections 8 and 9 as applicable. For purposes of this section, the term "covered person" includes the representative of a covered person. A description of the appeal and grievance procedure shall be set forth in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage provided to covered persons. The appeal and grievance procedure description shall include a statement of a covered person's right to contact the Superintendent's office for assistance at any time. The statement shall include the toll free telephone number, website address, and mailing address of the Bureau of Insurance. The notification must include a statement that assistance may be available through an office of health insurance consumer assistance or ombudsman established under the federal Affordable Care Act.

DRAFTING NOTE: The requirements of this section apply to grievances regarding medical issues (adverse health care treatment decisions) and also to grievances and adverse benefit determinations that do not involve medical issues.

02-031 C.M.R. ch. 850, § 10